Executive Summary: Standards of MedicalCare in Diabetes—2010

Current criteria for the diagnosis ofdiabetes● A1C �6.5%: The test should be per-

formed in a laboratory using a methodthat is National Glycohemoglobin Stan-dardization Program (NGSP) certifiedand standardized to the Diabetes Controland Complications Trial (DCCT) assay.

● FPG �126 mg/dl (7.0 mmol/l): Fasting isdefined as no caloric intake for at least8 h.

● 2-h plasma glucose �200 mg/dl (11.1mmol/l) during an oral glucose tolerancetest (OGTT): The test should be per-formed as described by the World HealthOrganization using a glucose load con-taining the equivalent of 75 g anhydrousglucose dissolved in water.

● In a patient with classic symptoms ofhyperglycemia or hyperglycemic crisis:a random plasma glucose �200 mg/dl(11.1 mmol/l).

Testing for diabetes in asymptomaticpatients● Testing to detect type 2 diabetes and

assess risk for future diabetes in asymp-tomatic people should be considered inadults of any age who are overweight orobese (BMI �25 kg/m2) and who haveone or more additional risk factors fordiabetes (see Table 4 of Standards ofMedical Care in Diabetes—2010). Inthose without these risk factors, testingshould begin at age 45 years. (B)

● If tests are normal, repeat testing shouldbe carried out at least at 3-year intervals.(E)

● To test for diabetes or to assess risk offuture diabetes, A1C, FPG , or 2-h 75-gOGTT are appropriate. (B)

● In those identified with increased riskfor future diabetes, identify and, if ap-propriate, treat other cardiovasculardisease (CVD) risk factors. (B)

Detection and diagnosis ofgestational diabetes mellitus● Screen for gestational diabetes mellitus

(GDM) using risk-factor analysis and, ifappropriate, the OGTT. (C)

● Women with GDM should be screenedfor diabetes 6–12 weeks postpartumand should be followed up with subse-quent screening for the development ofdiabetes or pre-diabetes. (E)

Prevention of type 2 diabetes● Patients with IGT (A), IFG (E), or an

A1C of 5.7– 6.4% (E) should be re-ferred to an effective ongoing supportprogram for weight loss of 5–10% ofbody weight and increase in physicalactivity to at least 150 min/week ofmoderate activity such as walking.

● Follow-up counseling appears to be im-portant for success. (B)

● Based on potential cost savings of dia-betes prevention, such counselingshould be covered by third-party pay-ors. (E)

● In addition to lifestyle counseling, met-formin may be considered in those whoare at very high risk for developing di-abetes (combined IFG and IGT plusother risk factors such as A1C �6%,hypertension, low HDL cholesterol, el-evated triglycerides, or family history ofdiabetes in a first-degree relative) andwho are obese and under 60 years ofage. (E)

● Monitoring for the development of di-abetes in those with pre-diabetesshould be performed every year. (E)

Glucose monitoring● Self-monitoring of blood glucose

(SMBG) should be carried out three ormore times daily for patients using mul-tiple insulin injections or insulin pumptherapy. (A)

● For patients using less frequent insulininjections, noninsulin therapies, or

medical nutrition therapy (MNT)alone, SMBG may be useful as a guide tothe success of therapy. (E)

● To achieve postprandial glucose tar-gets, postprandial SMBG may be appro-priate. (E)

● When prescribing SMBG, ensure thatpatients receive initial instruction in,and routine follow-up evaluation of,SMBG technique and their ability to usedata to adjust therapy. (E)

● Continuous glucose monitoring (CGM)in conjunction with intensive insulinregimens can be a useful tool to lowerA1C in selected adults (age �25 years)with type 1 diabetes. (A)

● Although the evidence for A1C-lowering is less strong in children,teens, and younger adults, CGM maybe helpful in these groups. Success cor-relates with adherence to ongoing useof the device. (C)

● CGM may be a supplemental tool toSMBG in those with hypoglycemia un-awareness and/or frequent hypoglyce-mic episodes. (E)

A1C● Perform the A1C test at least two times

a year in patients who are meeting treat-ment goals (and who have stable glyce-mic control). (E)

● Perform the A1C test quarterly in pa-tients whose therapy has changed orwho are not meeting glycemic goals. (E)

● Use of point-of-care testing for A1C al-lows for timely decisions on therapychanges, when needed. (E)

Glycemic goals in adults● Lowering A1C to below or around 7%

has been shown to reduce microvascu-lar and neuropathic complications oftype 1 and type 2 diabetes. Therefore,for microvascular disease prevention,the A1C goal for nonpregnant adults ingeneral is �7%. (A)

● In type 1 and type 2 diabetes, random-ized controlled trials of intensive versusstandard glycemic control have notshown a significant reduction in CVDoutcomes during the randomized por-tion of the trials. Long-term follow-upof the DCCT and UK Prospective Dia-

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DOI: 10.2337/dc10-S004© 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

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S4 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010 care.diabetesjournals.org

betes Study (UKPDS) cohorts suggeststhat treatment to A1C targets below oraround 7% in the years soon after thediagnosis of diabetes is associated withlong-term reduction in risk of macro-vascular disease. Until more evidencebecomes available, the general goal of�7% appears reasonable for manyadults for macrovascular risk reduc-tion. (B)

● Subgroup analyses of clinical trials suchas the DCCT and UKPDS and evidencefor reduced proteinuria in the AD-VANCE trial suggest a small but incre-mental benefit in microvascularoutcomes with A1C values closer tonormal. Therefore, for selected individ-ual patients, providers might reason-ably suggest even lower A1C goals thanthe general goal of �7%, if this can beachieved without significant hypogly-cemia or other adverse effects of treat-ment. Such patients might includethose with short duration of diabetes,long life expectancy, and no significantCVD. (B)

● Conversely, less stringent A1C goalsthan the general goal of �7% may beappropriate for patients with a historyof severe hypoglycemia, limited life ex-pectancy, advanced microvascular ormacrovascular complications, or exten-sive comorbid conditions and thosewith longstanding diabetes in whomthe general goal is difficult to attain de-spite diabetes self-management educa-tion, appropriate glucose monitoring,and effective doses of multiple glucose-lowering agents including insulin. (C)

Medical nutrition therapyGeneral recommendations● Individuals who have pre-diabetes or

diabetes should receive individualizedmedical nutrition therapy (MNT) asneeded to achieve treatment goals, pref-erably provided by a registered dietitianfamiliar with the components of diabe-tes MNT. (A)

● Because MNT can result in cost-savingsand improved outcomes (B), MNTshould be covered by insurance andother payors. (E)

Energy balance, overweight, andobesity● In overweight and obese insulin-

resistant individuals, modest weightloss has been shown to reduce insulinresistance. Thus, weight loss is recom-mended for all overweight or obese in-

dividuals who have or are at risk fordiabetes. (A)

● For weight loss, either low-carbohy-drate or low-fat calorie-restricted dietsmay be effective in the short-term (upto 1 year). (A)

● For patients on low-carbohydrate diets,monitor lipid profiles, renal function,and protein intake (in those with ne-phropathy) and adjust hypoglycemictherapy as needed. (E)

● Physical activity and behavior modifi-cation are important components ofweight loss programs and are mosthelpful in maintenance of weight loss.(B)

Primary prevention of diabetes● Among individuals at high risk for de-

veloping type 2 diabetes, structuredprograms emphasizing l i festylechanges including moderate weightloss (7% body weight) and regularphysical activity (150 min/week), withdietary strategies including reducedcalories and reduced intake of dietaryfat, can reduce the risk for developingdiabetes and are therefore recom-mended. (A)

● Individuals at high risk for type 2 dia-betes should be encouraged to achievethe U.S. Department of Agriculture(USDA) recommendation for dietary fi-ber (14 g fiber/1,000 kcal) and foodscontaining whole grains (one-half ofgrain intake). (B)

Dietary fat intake in diabetesmanagement● Saturated fat intake should be �7% of

total calories. (A)● Reducing intake of trans fat lowers LDL

cholesterol and increases HDL choles-terol (A); therefore, intake of trans fatshould be minimized. (E)

Carbohydrate intake in diabetesmanagement● Monitoring carbohydrate, whether by

carbohydrate counting, exchanges, orexperience-based estimation, remains akey strategy in achieving glycemic con-trol. (A)

● For individuals with diabetes, the use ofthe glycemic index and glycemic loadmay provide a modest additional bene-fit for glycemic control over that ob-served when total carbohydrate isconsidered alone. (B)

Other nutrition recommendations● Sugar alcohols and nonnutritive sweet-

eners are safe when consumed withinthe acceptable daily intake levels estab-lished by the Food and Drug Adminis-tration (FDA). (A)

● If adults with diabetes choose to usealcohol, daily intake should be limitedto a moderate amount (one drink perday or less for adult women and twodrinks per day or less for adult men).(E)

● Routine supplementation with antioxi-dants, such as vitamins E and C andcarotene, is not advised because of lackof evidence of efficacy and concern re-lated to long-term safety. (A)

● Benefit from chromium supplementa-tion in people with diabetes or obesityhas not been conclusively demon-strated and, therefore, cannot be rec-ommended. (C)

● Individualized meal planning shouldinclude optimization of food choicesto meet recommended dietary allow-ances (RDAs)/dietary reference intakes(DRIs) for all micronutrients. (E)

Bariatric surgery● Bariatric surgery should be considered

for adults with BMI �35 kg/m2 andtype 2 diabetes, especially if the diabe-tes or associated comorbidities are dif-ficult to control with lifestyle andpharmacologic therapy. (B)

● Patients with type 2 diabetes who haveundergone bariatric surgery need life-long lifestyle support and medicalmonitoring. (E)

● Although small trials have shown gly-cemic benefit of bariatric surgery in pa-tients with type 2 diabetes and BMI of30–35 kg/m2, there is currently insuf-ficient evidence to generally recom-mend surgery in patients with BMI �35kg/m2 outside of a research protocol.(E)

● The long-term benefits, cost-effective-ness, and risks of bariatric surgery inindividuals with type 2 diabetes shouldbe studied in well-designed random-ized controlled trials with optimalmedical and lifestyle therapy as thecomparator. (E)

Diabetes self-management education● People with diabetes should receive di-

abetes self-management education(DSME) according to national stan-dards when their diabetes is diagnosedand as needed thereafter. (B)

● Effective self-management and quality

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of life are the key outcomes of DSMEand should be measured and moni-tored as part of care. (C)

● DSME should address psychosocial is-sues, since emotional well-being isassociated with positive diabetes out-comes. (C)

● Because DSME can result in cost-savings and improved outcomes (B),DSME should be reimbursed by third-party payors. (E)

Physical activity● People with diabetes should be advised

to perform at least 150 min/week ofmoderate-intensity aerobic physical ac-tivity (50 –70% of maximum heartrate). (A)

● In the absence of contraindications,people with type 2 diabetes should beencouraged to perform resistance train-ing three times per week. (A)

Psychosocial assessment and care● Assessment of psychological and social

situation should be included as an on-going part of the medical managementof diabetes. (E)

● Psychosocial screening and follow-upshould include, but is not limited to,attitudes about the illness, expectationsfor medical management and out-comes, affect/mood, general and diabe-tes-related quality of life, resources(financial, social, and emotional), andpsychiatric history. (E)

● Screen for psychosocial problems suchas depression and diabetes-related dis-tress, anxiety, eating disorders, andcognitive impairment when self-management is poor. (C)

Hypoglycemia● Glucose (15–20 g) is the preferred

treatment for the conscious individualwith hypoglycemia, although any formof carbohydrate that contains glucosemay be used. If SMBG 15 min aftertreatment shows continued hypoglyce-mia, the treatment should be repeated.Once SMBG glucose returns to normal,the individual should consume a mealor snack to prevent recurrence of hypo-glycemia. (E)

● Glucagon should be prescribed for allindividuals at significant risk of severehypoglycemia, and caregivers or familymembers of these individuals in-structed in its administration. Gluca-gon administration is not limited tohealth care professionals. (E)

● Individuals with hypoglycemia un-

awareness or one or more episodes ofsevere hypoglycemia should be advisedto raise their glycemic targets to strictlyavoid further hypoglycemia for at leastseveral weeks, to partially reverse hypo-glycemia unawareness and reduce riskof future episodes. (B)

Immunization● Annually provide an influenza vaccine

to all diabetic patients 6 months of age.(C)

● Administer pneumococcal polysaccha-ride vaccine to all diabetic patients �2years of age. A one-time revaccination isrecommended for individuals �64years of age previously immunizedwhen they were �65 years of age if thevaccine was administered �5 yearsago. Other indications for repeat vacci-nation include nephrotic syndrome,chronic renal disease, and other immu-nocompromised states, such as aftertransplantation. (C)

Hypertension/blood pressure controlScreening and diagnosis● Blood pressure should be measured at

every routine diabetes visit. Patientsfound to have systolic blood pressure�130 mmHg or diastolic blood pres-sure �80 mmHg should have bloodpressure confirmed on a separate day.Repeat systolic blood pressure �130mmHg or diastolic blood pressure �80mmHg confirms a diagnosis of hyperten-sion. (C)

Goals● Patients with diabetes should be treated

to a systolic blood pressure �130mmHg. (C)

● Patients with diabetes should be treatedto a diastolic blood pressure �80mmHg. (B)

Treatment● Patients with a systolic blood pressure

of 130–139 mmHg or a diastolic bloodpressure of 80–89 mmHg may be givenlifestyle therapy alone for a maximumof 3 months, and then if targets are notachieved, be treated with addition ofpharmacological agents. (E)

● Patients with more severe hypertension(systolic blood pressure �140 or dia-stolic blood pressure �90 mmHg) atdiagnosis or follow-up should receivepharmacologic therapy in addition tolifestyle therapy. (A)

● Lifestyle therapy for hypertension con-sists of: weight loss if overweight, DASH-

style dietary pattern including reducingsodium and increasing potassium intake,moderation of alcohol intake, and in-creased physical activity. (B)

● Pharmacologic therapy for patients withdiabetes and hypertension should bewith a regimen that includes either anACE inhibitor or an angiotensin receptorblocker (ARB). If one class is not toler-ated, the other should be substituted. Ifneeded to achieve blood pressure targets,a thiazide diuretic should be added tothose with an estimated glomerular filtra-tion rate (GFR) (see below) �30 ml/minper 1.73 m2 and a loop diuretic for thosewith an estimated GFR �30 ml/min per1.73 m2. (C)

● Multiple drug therapy (two or moreagents at maximal doses) is generallyrequired to achieve blood pressure tar-gets. (B)

● If ACE inhibitors, ARBs, or diuretics areused, kidney function and serum potas-sium levels should be closely moni-tored. (E)

● In pregnant patients with diabetes andchronic hypertension, blood pressuretarget goals of 110–129/65–79 mmHgare suggested in the interest of long-term maternal health and minimizingimpaired fetal growth. ACE inhibitorsand ARBs are contraindicated duringpregnancy. (E)

Dyslipidemia/lipid managementScreening● In most adult patients, measure fasting

lipid profile at least annually. In adultswith low-risk lipid values (LDL choles-terol �100 mg/dl, HDL cholesterol�50 mg/dl, and triglycerides �150mg/dl), lipid assessments may be re-peated every 2 years. (E)

Treatment recommendations andgoals● Lifestyle modification focusing on the

reduction of saturated fat, trans fat, andcholesterol intake; increase of n-3 fattyacids, viscous fiber, and plant stanols/sterols; weight loss (if indicated); andincreased physical activity should berecommended to improve the lipidprofile in patients with diabetes. (A)

● Statin therapy should be added to life-style therapy, regardless of baselinelipid levels, for diabetic patients:● with overt CVD. (A)● without CVD who are over the age of

40 years and have one or more otherCVD risk factors. (A)

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● For lower risk patients than the above(e.g., without overt CVD and under theage of 40 years), statin therapy shouldbe considered in addition to lifestyletherapy if LDL cholesterol remainsabove 100 mg/dl or in those with mul-tiple CVD risk factors. (E)

● In individuals without overt CVD, theprimary goal is an LDL cholesterol�100 mg/dl (2.6 mmol/l). (A)

● In individuals with overt CVD, a lowerLDL cholesterol goal of �70 mg/dl (1.8mmol/l), using a high dose of a statin, isan option. (B)

● If drug-treated patients do not reach theabove targets on maximal tolerated sta-tin therapy, a reduction in LDL choles-terol of �30–40% from baseline is analternative therapeutic goal. (A)

● Triglycerides levels �150 mg/dl (1.7mmol/l) and HDL cholesterol �40mg/dl (1.0 mmol/l) in men and �50mg/dl (1.3 mmol/l) in women are desir-able. However, LDL cholesterol–targeted statin therapy remains thepreferred strategy. (C)

● If targets are not reached on maximallytolerated doses of statins, combinationtherapy using statins and other lipid-lowering agents may be considered toachieve lipid targets but has not beenevaluated in outcome studies for eitherCVD outcomes or safety. (E)

● Statin therapy is contraindicated inpregnancy. (E)

Antiplatelet agents● Consider aspirin therapy (75–162 mg/

day) as a primary prevention strategy inthose with type 1 or type 2 diabetes atincreased cardiovascular risk (10-yearrisk �10%). This includes most men�50 years of age or women �60 yearsof age who have at least one additionalmajor risk factor (family history ofCVD, hypertension, smoking, dyslipi-demia, or albuminuria). (C)

● There is not sufficient evidence to rec-ommend aspirin for primary preven-tion in lower risk individuals, such asmen �50 years of age or women �60years of age without other major riskfactors. In patients in these age-groupswith multiple other risk factors, clinicaljudgment is required. (C)

● Use aspirin therapy (75–162 mg/day)as a secondary prevention strategy inthose with diabetes with a history ofCVD. (A)

● For patients with CVD and docu-mented aspirin allergy, clopidogrel (75mg/day) should be used. (B)

● Combination therapy with ASA (75–162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year afteran acute coronary syndrome. (B)

Smoking cessation● Advise all patients not to smoke. (A)● Include smoking cessation counseling

and other forms of treatment as a rou-tine component of diabetes care. (B)

Coronary heart diseaseScreening● In asymptomatic patients, evaluate risk

factors to stratify patients by 10-yearrisk, and treat risk factors accordingly.(B)

Treatment● In patients with known CVD, ACE in-

hibitor (C) and aspirin and statin ther-apy (A) (if not contraindicated) shouldbe used to reduce the risk of cardiovas-cular events.

● In patients with a prior myocardial in-farction, B-blockers should be contin-ued for at least 2 years after the event.(B)

● Longer term use of B-blockers in theabsence of hypertension is reasonable ifwell tolerated, but data are lacking. (E)

● Avoid TZD treatment in patients withsymptomatic heart failure. (C)

● Metformin may be used in patients withstable congestive heart failure (CHF) ifrenal function is normal. It should beavoided in unstable or hospitalized pa-tients with CHF. (C)

Nephropathy screening andtreatmentGeneral recommendations● To reduce the risk or slow the progres-

sion of nephropathy, optimize glucosecontrol. (A)

● To reduce the risk or slow the progres-sion of nephropathy, optimize bloodpressure control. (A)

Screening● Perform an annual test to assess urine

albumin excretion in type 1 diabetic pa-tients with diabetes duration of �5years and in all type 2 diabetic patientsstarting at diagnosis. (E)

● Measure serum creatinine at least annu-ally in all adults with diabetes regard-less of the degree of urine albuminexcretion. The serum creatinine shouldbe used to estimate GFR and stage thelevel of chronic kidney disease (CKD),if present. (E)

Treatment● In the treatment of the nonpregnant pa-

tient with micro- or macroalbuminuria,either ACE inhibitors or ARBs shouldbe used. (A)

● While there are no adequate head-to-head comparisons of ACE inhibitorsand ARBs, there is clinical trial supportfor each of the following statements:● In patients with type 1 diabetes with

hypertension and any degree of albu-minuria, ACE inhibitors have beenshown to delay the progression of ne-phropathy. (A)

● In patients with type 2 diabetes, hy-pertension, and microalbuminuria,both ACE inhibitors and ARBs havebeen shown to delay the progressionto macroalbuminuria. (A)

● In patients with type 2 diabetes, hy-pertension, macroalbuminuria, andrenal insufficiency (serum creatinine�1.5 mg/dl), ARBs have been shownto delay the progression of nephrop-athy. (A)

● If one class is not tolerated, the othershould be substituted. (E) Reduction ofprotein intake to 0.8–1.0 g � kg bodywt–1 � day–1 in individuals with diabetesand the earlier stages of CKD and to0.8 g � kg body wt–1 � day–1 in the laterstages of CKD may improve measuresof renal function (urine albumin excre-tion rate, GFR) and is recommended.(B)

● When ACE inhibitors, ARBs, or diuret-ics are used, monitor serum creatinineand potassium levels for the develop-ment of acute kidney disease and hy-perkalemia. (E)

● Continued monitoring of urine albu-min excretion to assess both responseto therapy and progression of disease isrecommended. (E)

● Consider referral to a physician ex-perienced in the care of kidney dis-ease when there is uncertainty aboutthe etiology of kidney disease (activeurine sediment, absence of retinopathy,rapid decline in GFR), difficult manage-ment issues, or advanced kidney dis-ease. (B)

Retinopathy screening and treatmentGeneral recommendations● To reduce the risk or slow the progres-

sion of retinopathy, optimize glycemiccontrol. (A)

● To reduce the risk or slow the progres-sion of retinopathy, optimize bloodpressure control. (A)

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Screening● Adults and children aged 10 years or

older with type 1 diabetes should havean initial dilated and comprehensiveeye examination by an ophthalmologistor optometrist within 5 years after theonset of diabetes. (B)

● Patients with type 2 diabetes shouldhave an initial dilated and comprehen-sive eye examination by an ophthalmol-ogist or optometrist shortly after thediagnosis of diabetes. (B)

● Subsequent examinations for type 1and type 2 diabetic patients shouldbe repeated annually by an ophthal-mologist or optometrist. Less-frequentexams (every 2–3 years) may be consid-ered following one or more normal eyeexams. Examinations will be requiredmore frequently if retinopathy is pro-gressing. (B)

● High-quality fundus photographs candetect most clinically significant dia-betic retinopathy. Interpretation of theimages should be performed by atrained eye care provider. While retinalphotography may serve as a screeningtool for retinopathy, it is not a substi-tute for a comprehensive eye exam,which should be performed at least ini-tially and at intervals thereafter as rec-ommended by an eye care professional.(E)

● Women with preexisting diabetes whoare planning pregnancy or who havebecome pregnant should have a com-prehensive eye examination and becounseled on the risk of developmentand/or progression of diabetic retinop-athy. Eye examination should occur inthe first trimester with close follow-upthroughout pregnancy and for 1 yearpostpartum. (B)

Treatment● Promptly refer patients with any level of

macular edema, severe nonproliferativediabetic retinopathy (NPDR), or anyproliferative diabetic retinopathy(PDR) to an ophthalmologist who isknowledgeable and experienced in themanagement and treatment of diabeticretinopathy. (A)

● Laser photocoagulation therapy is indi-cated to reduce the risk of vision loss inpatients with high-risk PDR, clinicallysignificant macular edema, and in somecases of severe NPDR. (A)

● The presence of retinopathy is not acontraindication to aspirin therapy forcardioprotection, as this therapy does

not increase the risk of retinal hemor-rhage. (A)

Neuropathy screening and treatment● All patients should be screened for dis-

tal symmetric polyneuropathy (DPN) atdiagnosis and at least annually thereaf-ter, using simple clinical tests. (B)

● Electrophysiological testing is rarelyneeded, except in situations where theclinical features are atypical. (E)

● Screening for signs and symptoms ofcardiovascular autonomic neuropathyshould be instituted at diagnosis of type2 diabetes and 5 years after the diagno-sis of type 1 diabetes. Special testing israrely needed and may not affect man-agement or outcomes. (E)

● Medications for the relief of specificsymptoms related to DPN and auto-nomic neuropathy are recommended,as they improve the quality of life of thepatient. (E)

Foot care● For all patients with diabetes, perform

an annual comprehensive foot exami-nation to identify risk factors predictiveof ulcers and amputations. The foot ex-amination should include inspection,assessment of foot pulses, and testingfor loss of protective sensation (10-gmonofilament plus testing any one of:vibration using 128-Hz tuning fork,pinprick sensation, ankle reflexes, orvibration perception threshold). (B)

● Provide general foot self-care educationto all patients with diabetes. (B)

● A multidisciplinary approach is recom-mended for individuals with foot ulcersand high-risk feet, especially those witha history of prior ulcer or amputation.(B)

● Refer patients who smoke, have loss ofprotective sensation and structural ab-normalities, or have history of priorlower-extremity complications to footcare specialists for ongoing preventivecare and life-long surveillance. (C)

● Initial screening for peripheral arterydisease (PAD) should include a historyfor claudication and an assessment ofthe pedal pulses. Consider obtaining anankle-brachial index (ABI), as many pa-tients with PAD are asymptomatic. (C)

● Refer patients with significant claudica-tion or a positive ABI for further vascu-lar assessment and consider exercise,medications, and surgical options. (C)

Children and adolescentsGlycemic control

● Consider age when setting glycemicgoals in children and adolescents withtype 1 diabetes, with less stringent goalsfor younger children. (E)

Nephropathy● Annual screening for microalbumin-

uria, with a random spot urine samplefor microalbumin-to-creatinine ratio,should be initiated once the child is 10years of age and has had diabetes for 5years. (E)

● Confirmed, persistently elevated mi-croalbumin levels on two additionalurine specimens should be treated withan ACE inhibitor, titrated to normaliza-tion of microalbumin excretion if pos-sible. (E)

Hypertension● Treatment of high-normal blood pres-

sure (systolic or diastolic blood pres-sure consistently above the 90thpercentile for age, sex, and height)should include dietary interventionand exercise, aimed at weight controland increased physical activity, if ap-propriate. If target blood pressure is notreached with 3–6 months of lifestyleintervention, pharmacologic treatmentshould be initiated. (E)

● Pharmacologic treatment of hyperten-sion (systolic or diastolic blood pres-sure consistently above the 95thpercentile for age, sex, and height orconsistently greater than 130/80mmHg, if 95% exceeds that value)should be initiated as soon as the diag-nosis is confirmed. (E)

● ACE inhibitors should be consideredfor the initial treatment of hyperten-sion. (E)

● The goal of treatment is a blood pres-sure consistently �130/80 or below the90th percentile for age, sex, and height,whichever is lower. (E)

DyslipidemiaScreening● If there is a family history of hypercho-

lesterolemia (total cholesterol �240mg/dl) or a cardiovascular event beforeage 55 years, or if family history is un-known, then a fasting lipid profileshould be performed on children �2years of age soon after diagnosis (afterglucose control has been established).If family history is not of concern, thenthe first lipid screening should be per-formed at puberty (�10 years). All chil-dren diagnosed with diabetes at or afterpuberty should have a fasting lipid pro-

Executive Summary

S8 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010 care.diabetesjournals.org

file performed soon after diagnosis(after glucose control has been estab-lished). (E)

● For both age-groups, if lipids are abnor-mal, annual monitoring is recom-mended. If LDL cholesterol values arewithin the accepted risk levels (�100mg/dl [2.6 mmol/l]), a lipid profileshould be repeated every 5 years. (E)

Treatment● Initial therapy should consist of optimi-

zation of glucose control and MNTusing a Step II American Heart Associ-ation diet aimed at a decrease in theamount of saturated fat in the diet. (E)

● After the age of 10 years, the addition ofa statin is recommended in patientswho, after MNT and lifestyle changes,have LDL cholesterol �160 mg/dl (4.1mmol/l) or LDL cholesterol �130mg/dl (3.4 mmol/l) and one or moreCVD risk factors. (E)

● The goal of therapy is an LDL choles-terol value �100 mg/dl (2.6 mmol/l).(E)

Retinopathy● The first ophthalmologic examination

should be obtained once the child is 10years of age and has had diabetes for3–5 years. (E)

● After the initial examination, annualroutine follow-up is generally recom-mended. Less frequent examinationsmay be acceptable on the advice of aneye care professional. (E)

Celiac disease● Children with type 1 diabetes should

be screened for celiac disease by mea-suring tissue transglutaminase oranti-endomysial antibodies, withdocumentation of normal serum IgAlevels, soon after the diagnosis of di-abetes. (E)

● Testing should be repeated if growthfailure, failure to gain weight, weightloss, or gastroenterologic symptoms oc-cur. (E)

● Consideration should be given to peri-odic re-screening of asymptomatic in-dividuals. (E)

● Children with positive antibodiesshould be referred to a gastroenterolo-gist for evaluation. (E)

● Children with confirmed celiac diseaseshould have consultation with a dieti-tian and placed on a gluten-free diet.(E)

Hypothyroidism● Children with type 1 diabetes should be

screened for thyroid peroxidase andthyroglobulin antibodies at diagnosis.(E)

● TSH concentrations should be mea-sured after metabolic control hasbeen established. If normal, theyshould be rechecked every 1–2 years,or if the patient develops symptomsof thyroid dysfunction, thyromegaly,or an abnormal growth rate. Free T4should be measured if TSH is abnor-mal. (E)

Preconception care● A1C levels should be as close to normal

as possible (�7%) in an individual pa-tient before conception is attempted.(B)

● Starting at puberty, preconceptioncounseling should be incorporated inthe routine diabetes clinic visit for allwomen of child-bearing potential. (C)

● Women with diabetes who are contem-plating pregnancy should be evaluatedand, if indicated, treated for diabeticretinopathy, nephropathy, neuropathy,and CVD. (E)

● Medications used by such womenshould be evaluated prior to concep-tion, since drugs commonly used totreat diabetes and its complicationsmay be contraindicated or not recom-mended in pregnancy, including st-atins, ACE inhibitors, ARBs, and mostnoninsulin therapies. (E)

Older adults● Older adults who are functional, cogni-

tively intact, and have significant lifeexpectancy should receive diabetes careusing goals developed for youngeradults. (E)

● Glycemic goals for older adults notmeeting the above criteria may be re-laxed using individual criteria, but hy-perglycemia leading to symptoms orrisk of acute hyperglycemic complica-tions should be avoided in all patients.(E)

● Other cardiovascular risk factorsshould be treated in older adults withconsideration of the time frame of ben-efit and the individual patient. Treat-ment of hypertension is indicated invirtually all older adults, and lipid andaspirin therapy may benefit those withlife expectancy at least equal to the timeframe of primary or secondary preven-tion trials. (E)

● Screening for diabetes complicationsshould be individualized in olderadults, but particular attention shouldbe paid to complications that wouldlead to functional impairment. (E)

Diabetes care in the hospital● All patients with diabetes admitted to

the hospital should have their diabetesclearly identified in the medical record.(E)

● All patients with diabetes should havean order for blood glucose monitoring,with results available to all members ofthe health care team. (E)

● Goals for blood glucose levels:● Critically ill patients: Insulin ther-

apy should be initiated for treat-ment of persistent hyperglycemiastarting at a threshold of no greaterthan 180 mg/dl (10 mmol/l). Onceinsulin therapy is started, a glucoserange of 140 –180 mg/dl (7.8 to 10mmol/l) is recommended for themajority of critically ill patients. (A)These patients require an intrave-nous insulin protocol that has dem-onstrated efficacy and safety inachieving the desired glucose rangewithout increasing risk for severehypoglycemia. (E)

● Non– critically ill patients: There isno clear evidence for specific bloodglucose goals. If treated with insu-lin, the premeal blood glucose tar-get should generally be �140 mg/dl(7.8 mmol/l) with random bloodglucose �180 mg/dl (10.0 mmol/l),provided these targets can be safelyachieved. More stringent targetsmay be appropriate in stable pa-tients with previous tight glycemiccontrol. Less stringent targets maybe appropriate in those with severecomorbidites. (E)

● Scheduled subcutaneous insulin withbasal, nutritional, and correction.Components is the preferred methodfor achieving and maintaining glucosecontrol in noncritically ill patients. (C)Using correction dose or “supplemen-tal” insulin to correct premeal hyper-glycemia in addition to scheduledprandial and basal insulin is recom-mended. (E)

● Glucose monitoring should be initiatedin any patient not known to be diabeticwho receives therapy associated withhigh risk for hyperglycemia, includinghigh-dose glucocorticoid therapy, initi-ation of enteral or parenteral nutrition,

Executive Summary

care.diabetesjournals.org DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010 S9

or other medications such as octreotideor immunosuppressive medications.(B) If hyperglycemia is documentedand persistent, treatment is necessary.Such patients should be treated to thesame glycemic goals as patients withknown diabetes. (E)

● A plan for treating hypoglycemiashould be established for each patient.Episodes of hypoglycemia in the hospi-tal should be tracked. (E)

● All patients with diabetes admitted tothe hospital should have an A1C ob-tained if the result of testing in the

previous 2–3 months is not available.(E)

● Patients with hyperglycemia in the hos-pital who do not have a diagnosis ofdiabetes should have appropriate plansfor follow-up testing and care docu-mented at discharge. (E)

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S10 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010 care.diabetesjournals.org